摘要：
目的 探索急性肠系膜血管闭塞性疾病发生肠坏死的预测因素及其对于开腹探查术时机选择的意义.方法 回顾性分析北京大学人民医院于1995年7月至2015年6月期间收治的63例急性肠系膜血管闭塞性疾病患者的临床和实验室资料.依据单因素及多因素Logistic回归分析,探索肠坏死发生的预测因素.结果 全组男性39例(61.9%),女性24例(38.1%),年龄为31~82(58.8±12.7)岁;其中有29例(46.0%)患者发生肠坏死.随访13~268(中位数29)个月,肠坏死者中有72.4%(21/29)完成随访;未发生肠坏死者有85.3%(29/34)完成随访;两组预后的差异有统计学意义(χ2=5.908,P=0.015).单因素分析显示,全身炎性反应综合征(χ2=18.535,P=0.000)、休克(χ2=7.775,P=0.007)、腹膜刺激征(χ2=11.533,P=0.001)、B超或CT发现肠壁改变及血流信号异常(χ2=14.344,P=0.000)、国际标准化(凝血酶原时间)比值(χ2=4.498,P=0.034)、D-二聚体(χ2=6.680,P=0.010)、乳酸脱氢酶(χ2=6.513,P=0.011)、血清白蛋白(χ2=3.914,P=0.048)、血尿素氮(χ2=11.377,P=0.001)、血pH值(χ2=15.887,P=0.000)、血乳酸(χ2=17.134,P=0.000)以及碱剩余(χ2=6.674,P=0.010)与急性肠系膜血管闭塞性疾病患者发生肠坏死有关.进一步多因素Logistic回归分析显示,全身炎性反应综合征(OR=28.945,95%CI:2.294~365.199,P=0.009)、血pH值<7.35(OR=13.174,95%CI:1.157~150.027,P=0.038)、B超或CT发现肠壁改变及血流信号异常(OR=4.857,95%CI:1.110~21.253,P=0.036)为急性肠系膜血管闭塞性疾病发生肠坏死的独立预测因素.结论 发生肠坏死的急性肠系膜血管闭塞性疾病患者预后不良.出现酸中毒、全身炎性反应综合征以及B超(或CT)发现肠壁改变和血流信号异常时应警惕肠坏死的发生,并争取尽早行手术探查,以明确肠管活力并及时干预.%Objective To explore the predictive factors of intestinal necrosis in acute mesenteric vascular occlusive diseases and its significance for the timing of exploratory laparotomy. Methods This retrospective study enrolled 63 patients diagnosed as acute mesenteric vascular occlusive diseases at Peking University People' s Hospital between July 1995 and June 2015. Univariate analysis and multivariate logistic regression analysis were used to identify predictive factors for intestinal necrosis. Results Of 63 patients, 39 were male and 24 were female, with a mean age of (58.8 ± 12.7)(31 to 82) years. The overall rate of intestinal necrosis was 46.0%(29/63). Patients with intestinal necrosis had a poorer prognosis than those who did not develop intestinal necrosis (χ2=5.908, P=0.015). In univariate analysis, the predictive factors of intestinal necrosis were systemic inflammatory reactive syndrome (SIRS) (χ2=18.535, P = 0.000), shock (χ2=7.775, P = 0.007), peritoneal irritation sign (χ2=11.533, P = 0.001), changes of intestinal wall and blood signals on ultrasound or CT scans (χ2=14.344, P=0.000), international normalized ratio (INR) (prothrombin time) ≥1.2 (χ2=4.498, P = 0.034), D-dimer≥1000 g/L(χ2=6.680, P = 0.010), low-density lipoprotein ≥270 U/L (χ2 =6 . 513 , P = 0 . 011 ) , serum albumin < 35 g/L (χ2 = 3 . 914 , P = 0 . 048 ) , blood urea nitrogen≥ 6.2 mmol/L (χ2= 11.377, P = 0.000), pH values < 7.35 (χ2= 15.887, P = 0.000), blood lactate≥2 mmol/L (χ2=17.134, P=0.000), base excess < -1.0 mmol/L (χ2=6.674, P = 0.010). According to multivariate logistic regression analysis, SIRS(OR=28.945, 95%CI:2.294 to 365.199, P = 0.009), pH values < 7.35 (OR=13.174, 95%CI:1.157 to 150.027, P = 0.038), changes of intestinal wall and blood signals on ultrasound or CT scans (OR = 4.857, 95%CI:1.110 to 21.253, P=0.036) were independent predictive factors of intestinal necrosis in patients with acute mesenteric vascular occlusive diseases. Conclusions Intestinal necrosis in acute mesenteric vascular occlusive diseases prompts a poor prognosis. When patients with acute mesenteric vascular occlusive diseases are found to have acidosis, SIRS and changes of intestinal wall and blood signals on ultrasound or CT scans, surgeons should be alert to the occurrence of intestinal necrosis and should perform laparotomy promptly in order to take suitable management.
